Hormone Replacement for Women. Primer Part 2: Progesterone and Testosterone

by Lael Luedtke, MD

This is our third article on hormone replacement for women in peri-menopause and menopause. We’ve worked to dispel common misconceptions and provide some nuance to a topic that is too often oversimplified in social media and influencer babble. The primary message of this series is that the hormonal changes as women age are complex and warrant using all the available tools in a thoughtful, deliberate fashion. 

To recap:

• In our first article, we covered the misconceptions on the pros and cons of HRT, and we discussed the three different hormones that we can consider to support women – estrogen, progesterone and testosterone. 

• In our next article, we covered estrogen in depth, both the older (and out-of-date) treatments being used and more advanced options. 

In this article, let’s delve more deeply into the other two hormones mentioned, progesterone and testosterone. Both of these hormones can play important roles in helping women optimize their well being in peri-menopause and menopause, but some important details matter and are worth explaining.

Considerations for Progesterone

Progestogens are a category of hormones that includes both progesterone as well as progestins. Many women have used progestins in the form of birth control, either as pills or intra-uterine devices (IUDs). Progestins are very potent, synthetic compounds that very effectively turn off the ovaries and prevent ovulation. Progesterone is the bio-identical form that is used more commonly in peri-menopause or menopause.  

For women who still have a uterus and are using estrogen replacement, progesterone is a critical necessity to safeguard against the risk of uterine cancer. There are two options in terms of how to dose progesterone. It can be used for 12-14 days per month, with bleeding occurring when the progesterone is withdrawn. Alternatively, it can be used daily, thereby avoiding bleeding. Progesterone is most typically dosed at night and thus can aid in common sleep issues. Progesterone also can benefit mood. Progesterone may also be used in the absence of a uterus to help symptomatically with menopause.  

Progesterone is the preferred means of hormone replacement, as progestins do have an increased risk of blood clots, not seen with progesterone. Progesterone is administered at nighttime orally or vaginally, as it is poorly absorbed through the skin. Some women don’t tolerate progesterone (excessive grogginess, bloating, abdominal cramping) and in those cases, progestins might be used. As always, treatment must be tailored to a woman’s specific situation and needs.

Testosterone Declines More Gradually

While estrogen and progesterone drop abruptly with menopause, testosterone decline gradually over time, starting at about 30 years of age in women. Diminished testosterone can impact libido, sexual function, muscle mass, energy levels, urinary continence and ability to focus. Testosterone may also be helpful in avoiding the muscle loss seen with the use of GLP-1 drugs.

Testosterone levels should be checked prior to initiating therapy and again a few months into replacement, to make sure that absorption is happening. As a general rule of thumb, women’s testosterone levels would be around one-tenth that of men. A protein called sex hormone binding globulin (SHBG) should also be measured as that can impact how much of the testosterone in the bloodstream is actually available for the body to use.

Replacement of testosterone for women can be challenging as there is no testosterone product specifically approved for women. Use of a testosterone gel daily is a common approach and the least expensive route of replacement. Just as a women’s testosterone level is one-tenth that of men, the replacement dose is likewise one-tenth that of men. Accordingly, a box of 1% testosterone gel is nearly a year’s supply for a woman. Using compounded products or pellets is not recommended due to increased cost or because the doses can be too high. Some women note oily skin/acne, hair loss or facial hair as a side effect, but this can be addressed through decreasing the dose or taking a break from replacement therapy. Patience is required as often the impact of testosterone replacement is slow to become apparent, sometimes requiring 4-6 months of daily use before changes are seen.

Both progesterone and testosterone can be incredibly helpful in mitigating some of the profound impacts of menopause. Progesterone makes estrogen replacement safer for women with a uterus and can separately enhance sleep quality. Testosterone can have widespread impact on quality of life for women. With all the tools available, women can expect to feel good and function well in this phase of life.